Nicolas Graveleau

The rectus femoris is the most commonly injured muscle of the anterior thigh among athletes, especially soccer players. Although the injury pattern of the muscle belly is well documented, less is known about the anatomy and specific lesions of the proximal tendons. For each head, three distinctive patterns may be encountered according to the location of the injury, which can be at the enthesis, within the tendon, or at the musculotendinous junction. In children, injuries correspond most commonly to avulsion of the anteroinferior iliac spine from the direct head and can lead to subspine impingement. Calcific tendinitis and traumatic tears may be encountered in adults. Recent studies have shown that traumatic injuries of the indirect head may be underdiagnosed and that injuries of both heads may have a surgical issue. Finally, in the case of tears, functional outcome and treatment may vary if the rupture involves one or both tendons and if the tear is partial or complete. Thus, it is ...

Resume Introduction Les resultats a 20 ans de recul apres ligamentoplastie du croise anterieur sont rares. Cette etude a ete realisee afin d’etudier la prevalence de la gonarthrose a plus de 20 ans de recul d’une ligamentoplastie du croise anterieur et de determiner les facteurs de risque. Hypothese : Les lesions meniscales, le niveau d’activite, le delai traumatisme–chirurgie, l’indice de masse corporelle, la laxite residuelle, le positionnement des tunnels et les lesions cartilagineuses traumatiques influencent l’evolution vers la gonarthrose. Materiel et methodes Cette serie retrospective multicentrique regroupait 182 patients. Elle a ete realisee dans le cadre d’un symposium SOFCOT dont deux tiers des effectifs etaient des femmes. La technique chirurgicale etait arthroscopique dans 82 % des cas et un transplant de type os–ligament patellaire–os etait utilise dans 92,8 % des cas. L’âge moyen a la chirurgie etait de 26 + 7 ans. Les scores cliniques recueillis etaient l’IKDC objectif et subjectif, le KOOS. Les signes radiographiques d’arthrose etaient classes selon l’IKDC. Les facteurs predictifs d’arthrose etudies etaient l’âge, le sexe, l’IMC, le niveau d’activite, le delai traumatisme–chirurgie, les meniscectomies, les chondropathies, le positionnement des tunnels et la laxite residuelle. Resultats Au dernier recul, pour l’IKDC objectif il y avait 48 % de genoux normaux (A), 35 % d’anormaux (B) et 17 % de pathologiques (C et D). Le score IKDC subjectif moyen etait de 82,7 + 13,1. Une arthrose moderee a severe etait presente dans 29 % des cas. Les facteurs de risque de gonarthrose identifies etaient : la meniscectomie mediale ou laterale, la laxite residuelle, l’âge a la chirurgie > 30 ans et la pratique d’un sport comprenant du pivot. La meniscectomie etait un facteur essentiel de survenue d’arthrose (17 % si les menisques etaient preserves et 46 % en cas de meniscectomie). Enfin le taux de re-rupture etait de 13 %. Conclusion La reconstruction du LCA donne des resultats satisfaisants sur la stabilisation du genou mais le devenir cartilagineux depend principalement du statut meniscal. La laxite sequellaire a egalement un role favorisant la gonarthrose. Niveau de preuve IV, etude retrospective de cohorte.

Aims MRI has been suggested as an objective method of assessing anterior crucate ligament (ACL) graft “ligamentization” after reconstruction. It has been proposed that the MRI appearances could be used as an indicator of graft maturity and used as part of a return-to-sport assessment. The aim of this study was to evaluate the correlation between MRI graft signal and postoperative functional scores, anterior knee laxity, and patient age at operation. Methods A consecutive cohort of 149 patients who had undergone semitendinosus autograft ACL reconstruction, using femoral and tibial adjustable loop fixations, were evaluated retrospectively postoperatively at two years. All underwent MRI analysis of the ACL graft, performed using signal-to-noise quotient (SNQ) and the Howell score. Functional outcome scores (Lysholm, Tegner, International Knee Documentation Committee (IKDC) subjective, and IKDC objective) were obtained and all patients underwent instrumented side-to-side anterior laxity...

Introduction Lors d’une reconstruction du Ligament Croise Anterieur (LCA), l’autogreffe aux ischio-jambiers (IJ) va passer par une phase de transformation et de maturation pour acquerir sa resistance definitive. Des etudes entre la maturation, le signal IRM et les resultats fonctionnels ont ete rapportees mais aucune etude n’a analyse l’effet de l’âge sur la maturation. Nous avons donc analyse le signal de la greffe de LCA a 2 ans en fonction de l’âge avec l’hypothese que l’âge influencait l’evolution du signal IRM. Materiel et methode Il s’agissait d’une etude prospective comparative de 2 groupes : 1 groupe de 76 patients de moins de 35 ans (> 35) et 1 groupe de 73 patients plus de 35 ans (> 35). Les criteres d’inclusion comprenaient une reconstruction primaire du LCA avec utilisation d’une autogreffe aux ischio-jambiers fixee par deux endoboutons, 2 ans de recul minimum et une absence de rerupture ou de reoperation de la plastie de LCA. L’analyse IRM de la greffe utilisait le Signal/Noise Quotient (SNQ) et le score de Howell. Resultats La moyenne d’âge etait de 24,8 ± 5,5 ans dans le groupe > 35 et de 46,2 ± 7,4 ans dans le groupe > 35, Le SNQ moyen etait de 1,2 ± 1,6 dans le groupe > 35 et de 2,8 ± 4,2 dans le groupe > 35 avec une difference significative entre les 2 groupes (p > 0,05). On retrouvait respectivement 64 %, 23 %, 12 % et 1 % de grade de Howell 1, 2, 3 et 4 dans le groupe > 35 et 60 %, 26 %, 14 % et 0 dans le groupe > 35 sans difference significative. Discussion La maturation de la greffe de LCA aux IJ se fait principalement lors des 6 premiers mois mais dure 2 ans. Nous avons retrouve que les patients de moins de 35 ans ont statistiquement une meilleure maturation de l’autogreffe a 2 ans de recul avec un SNQ plus bas, sans confirmation par le score de Howell qui est plus subjectif. La correlation entre le signal et le resultat fonctionnel est debattue mais un SNQ bas pourrait favoriser la reprise des activites. Conclusion Il s’agit d’une etude originale retrouvant un effet de l’âge sur la transformation de l’autogreffe de LCA aux IJ. Nous poursuivons le suivi prospectif des patients pour determiner l’evolution du signal IRM de la greffe a plus long recul afin de rechercher le maintien d’une difference mais aussi un impact sur les taux de rerupture.

Background: The success of anterior cruciate ligament (ACL) reconstruction requires solid graft incorporation within the tunnels to enable graft remodeling. Resorbable interference screws (RIS) provide limited tendon-bone contact because much of the tunnel circumference is occupied by the screw itself, while adjustable suspensory fixation (ASF) systems provide larger contact zones, which favor ligamentization. Purpose: To evaluate ligamentization of a 4-strand semitendinosus (4ST) graft fixed with ASF compared with RIS within the tibial bone tunnel at 6 months postoperatively using magnetic resonance imaging (MRI). Study Design: Cohort study; Level of evidence, 2. Methods: We prospectively enrolled 121 consecutive patients undergoing primary ACL reconstruction using a single-bundle 4ST graft. The femoral end of the graft was fixed using suspensory fixation in all knees. The tibial end of the graft was fixed using ASF in 67 knees and RIS in 54 knees. Six months postoperatively, knee ...

Despite the numerous techniques described regarding isolated anterior cruciate ligament (ACL) reconstruction, many authors have reported that residual knee rotational instability is not always eliminated. The combination of lateral extra-articular knee tenodesis and ACL reconstruction is an alternative surgical approach with very promising clinical results. The purpose of this article is to describe a reliable and reproducible technique of combined ACL reconstruction and lateral extra-articular knee tenodesis using a continuous looped hamstring tendon autograft. A 4-strand graft inside the joint and a 2-strand graft for the tenodesis are attached to 2 adjustable-loop button suspensory fixation devices.

Osteoconductive additives are used in resorbable interference screws for anterior cruciate ligament (ACL) reconstruction to improve graft incorporation and mitigate adverse effects. There are no published studies that compare biological performances of bioresorbable and biocomposite screws without artifacts due to different follow-up times and intrinsic patient characteristics. The purpose of this study was to evaluate the efficacy of osteoconductive agents in bioresorbable screws for ACL reconstruction at minimum follow-up of 2 years by intrapatient comparison. The hypothesis was that osteoconductive ceramics would result in slower resorption, improved ossification, and less tunnel widening. Cohort study; Level of evidence, 2. A total of 28 ACL reconstructions at 2 centers were randomly assigned into 2 comparable groups: (1) the graft was fixed in the tibia using standard bioresorbable screws and in the femur using biocomposite screws with osteoconductive agents (biphasic calcium p...

All meniscal repairs have become increasingly popular and have tended to convert meniscal suturing into a standard procedure. The most classical complications are neurovascular damage in relation to the minimal invasive approach for arthroscopic posteromedial and posterolateral portals as well as insertions of implants without direct visualization of the neurovascular structures. With the evolution of meniscal devices and implants, new complications in meniscal repair surgery have emerged, especially with first-generation implants (arrow, dart, staples, and screws). Repair techniques have also been developed. Over the years, many reports on specific complications relating to all-interior devices have been published. Chondral injuries, implant loosening, device migration, capsular or neural irritations, foreign body reactions, and cystic granulomas have all been described in the literature following the use of meniscal fixation devices. Since hybrid meniscal devices allow for easier meniscal sutures with lower risk of neurovascular injury, more appropriate suture placement, and the easy handling of the instruments, information delivered to patients regarding potential complications should take into account the rarefaction of complications reported in the literature.

Recurrent anterior dislocations associated with full thickness rotator cuff tear (RCT) carry a difficult therapeutic problem: should we treat instability and rotator cuff tear at the same time or only one of both pathologies? The goal of this study was to analyse a retrospective series of patients operated on to try to answer this question. Twenty-eight shoulders (27 patients) were operated on between 1988 and 2002. The mean age at first dislocation was 47 years (16-65), the average delay between first dislocation and operation was 6.1 years. Twenty-four shoulders presented with recurrent dislocations and four shoulders with recurrent subluxations; the average number of dislocations was 2.6 (1-20). Preoperatively, Hill-Sachs lesion was present in 96%, anterior glenoid rim fracture in 53.5% and glenohumeral osteoarthritis was observed in 37.5%. All the cases had full thickness rotator cuff tears: isolated supraspinatus in 43%,, Supra- plus infraspinatus in 35%, supraspinatus plus sub...

ABSTRACT Hypothèse Les ruptures du subscapulaire peuvent être évoquées cliniquement devant une rotation externe passive augmentée en comparatif par rapport au côté opposé, des manœuvres de rotation interne contrariée (Lift-Off test [LOT], Belly-Press test [BPT], Napoléon test et Bear-Hug test [BHT]) et des signes de rappel automatique positifs (Internal Rotation Lag Sign et Belly-Off Sign). Le biceps est fréquemment associé aux lésions du subscapulaire car ce dernier participe à la formation de la poulie médiale. Le Palm-Up test [PUT] est utilisé pour le biceps comme le test de Jobe pour le supraépineux. Patients et méthode Dans le cadre d’une étude multicentrique, nous avons souhaité évaluer la valeur diagnostique positive des tests cliniques LOT, BPT, BHT, PUT et de Jobe, pour les lésions du subscapulaire et leur importance anatomique. Les relations entre les différents paramètres étudiés ont été comparées statistiquement en utilisant une analyse de la variance. Cette étude prospective multicentrique de janvier 2009 à février 2010 comprenait 208 cas de lésions du subscapulaire isolées ou associées à une atteinte partielle (Ellman 1, 2, 3) ou transfixiante (stade 1 de la SFA) du supraépineux. Résultats La sévérité de l’atteinte du subscapulaire a été quantifiée selon la classification de la SFA (en quatre stades) et selon la hauteur de l’atteinte (tiers proximal et tiers supérieur). Les trois tests LOT, BPT et BHT étaient corrélés à sévérité des lésions observées (p < 0,05). Plus le test était déficitaire, plus l’atteinte était anatomiquement sévère. Le LOT est le test le moins réalisable (18 %) mais quand il est présent, il préjuge de lésions très sévères. Le BHT était le test le plus sensible de tous les tests (82 %). L’atteinte du biceps était d’autant plus fréquente que la sévérité de la lésion du subscapulaire était importante. Il n’y avait pas de corrélation significative entre les lésions du biceps et les tests du subscapulaire, ni entre les lésions du supraépineux et les tests du subscapulaire. Le PUT n’avait aucune corrélation avec les lésions du subscapulaire des lésions associées du supraépineux, en revanche, il était significativement corrélé aux lésions du biceps (p < 0,05). Le test de Jobe quant à lui était décevant car il était souvent positif même pour des lésions isolées du subscapulaire. Conclusion Malgré la réalisation des trois tests (LOT, BPT, BHT), 24 % des lésions du subscapulaire n’étaient diagnostiquées qu’en peropératoire. L’apport des signes de rappel automatique dans l’amélioration du diagnostic lésionnel n’a pas été étudié dans ce travail. Niveau de preuve II.

ABSTRACT Purpose of the studyTotally arthroscopic repair of rotator cuff tears is now common practice. The techniques used were evaluated by a retrospective multicentric analysis conducted by the French Society of Arthroscopy.Material and methodsThe series was limited to arthroscopic repair of full thickness tears of the supraspinatus or infraspinatus evaluated using the Constant score and arthro-MRI or arthroscan performed with at least one year follow-up. Data were processed with SPSS 10. The series included 576 patients who underwent surgery between January 2001 and June 2003. Mean patient age was 57.7 years; 52% were men and 60% were manual laborers. The mean preoperative Constant score was 46.4 ± 13.4/100. The tear was limited to the supraspinatus in 69% of shoulders, with extension to the upper third of the infraspinatus in 23.5% and the entire infraspinatus in 7.5%. The supraspinatus tear was distal in 41.7% of shoulders, intermediary in 44% and retracted in 14.3%. Fatty degeneration of the supraspinatus was noted grade 0 in 60%, 1 in 27%, 2 in 11% and 3 in 2%. Arthroscopic repair was performed in all cases, with locoregional anesthesia in 60.9%. Bioresorbable implants were used in 33% and metallic implants in 62.1%. Acromioplasty was performed in 92.7% and capsulotomy in 14.9%.ResultsOn average, the subjective outcome was scored 8.89/10. The Constant score improved from 46.3 ± 13.4 to 82.7 ± 10.3 with 62% having a strictly pain free shoulder. Muscle force improved from 5.8 ± 3.7 to 13.6 ± 5.4. Outcome was excellent in 94% of shoulders at 18.5 months mean follow-up. The complication rate in this series was 6.2% with 3.1% prolonged stiffness, 2.7% reflex dystrophy, 0.2% infection, and 0.2% anchor migration. The cuff was considered normal in 55.7% of shoulders with an intratendon addition image in 19%, i.e. 74.7% of non-ruptured cuffs. Minimal loss of integrity was noted in 9.5% and was marked in 15.7%, i.e. 25.2% iterative tears.Anatomoclinical correlationsThe Constant score was strongly correlated with rotator cuff integrity (p < 0001). This correlation was also found for force (p < 0001), motion (0.01) and activity (0.04), but not for pain. The clinical outcome was correlated with extension, retraction, intrasubstance tear, and fatty degeneration of the lesion preoperatively. Anatomic results were statistically less favorable for tears which were older, extensive, retracted or associated with fatty degeneration. Age was correlated with extent of the initial tear and also with less favorable anatomic and clinical outcome. Occupational accidents were correlated with less favorable clinical outcome.Conclusion Functional improvement after healing is a strong argument for repair. Arthroscopy has the advantage of combining a low complication rate with good clinical and anatomic results. Age is correlated with functional outcome and healing, but is not a contraindication.

This article describes a new technique for the arthroscopic treatment of distal clavicle fractures. This technique requires the use of posterior and anterior standard arthroscopic portals. The base of the coracoid process is exposed through the rotator interval. The ancillary system drill guide is placed at the undersurface of the coracoid process. A small incision is performed above the clavicular body and the corresponding part of the guide is pushed down to the clavicle. A 4-mm hole is drilled through the clavicle and the coracoid process. A double button device is pushed through both the holes. The first button is pushed below the coracoid. The device is tightened and the second button is fixed on top of the clavicular cortical bone, allowing reduction and fixation of the fracture. Four patients treated with this technique were evaluated at 6 months postoperatively. All patients showed bony union and a full recovery of the shoulder function. The technique provides firm fixation of fractures of the distal clavicle.

Introduction Les arthrites septiques apres reconstruction du ligament croise anterieur sont une complication rare, mais potentiellement grave, qui necessite un traitement rapide et codifie pour assurer la guerison et preserver la greffe. But de l’etude Rapporter les resultats d’un protocole therapeutique applique systematiquement a des patients suspects d’infection profonde aigue apres une reconstruction du LCA, issus d’une large population sur une courte periode. Dessin de l’etude Etude retrospective monocentrique ; Level of evidence, 4. Materiel et methode Une analyse retrospective d’une serie monocentrique consecutive de 4597 patients chez qui une ligamentoplastie du LCA a ete realisee entre 2011 et 2013, a ete menee. Tous les patients suspects d’arthrite postoperatoire precoce ont ete soumis au protocole arthroscopie, prelevements bacteriologiques multiples, conservation de la greffe et antibiotherapie (APCA). Ce protocole consiste en : des prelevements bacteriologiques multiples (×5) profonds, realises a l’occasion d’une arthroscopie qui a aussi pour but de faire un debridement, voire une synovectomie du genou, tout en respectant l’integrite de la greffe recente. Ce geste chirurgical permet de diminuer l’inoculum bacterien. Il est suivi d’une antibiotherapie d’abord probabiliste (bitherapie) puis adaptee secondairement aux resultats des cultures et de l’antibiogramme, poursuivie pendant 6 semaines ou arretee si les prelevements sont negatifs. Les donnees demographiques, l’incidence de l’infection, le type d’agent pathogene responsable et les methodes de traitement ont ete analyses. Resultats Le protocole APCA a ete applique a 24 patients dont 18 presentaient reellement une arthrite infectieuse aigue bacteriologiquement documentee sur les 4597 ligamentoplasties soit 0,39 %. Toutes les arthrites ont pu etre gueries avec le protocole applique comprenant un seul geste arthroscopique, sans sacrifice de la greffe, associe a une antibiotherapie prolongee, adaptee aux resultats bacteriologiques. Aucun des patients n’a eu de recidive infectieuse. Une analyse multivariee n’a pas permis de retrouve de facteur favorisant de la survenue d’une infection parmi les criteres suivants : âge, sexe, type de sport, operateur, type de greffe. Nos resultats sont comparables a ceux de la litterature, tant pour le taux d’infection que pour les antibiotiques proposes en fonction des germes. Conclusion L’arthrite septique aigue postoperatoire dans le cadre des reconstructions du LCA est une complication exceptionnelle qui peut etre traitee par une prise en charge precoce codifiee permettant la conservation de la greffe.

The success of shoulder stabilization with the Latarjet procedure might depend on the size of the bone graft and the positioning of the coracoid at the glenoid. The aim of this study was to quantitatively assess the surface of the coracoid bone graft and to assess its positioning in the en-face view. A series of 21 patients (17 men, 4 women, 26.1 ± 6.8 years-9 right, 12 left shoulders) were prospectively included and followed up with CT scans between December 2010 and April 2012 at an average of 2.4 ± 0.7 months postoperatively. The retrospective analysis of the CT scans was performed with Osirix™ software. The coracoid surface was measured (cm(2)) in the sagittal plane. The positioning in relation to the center of the circumscribed circle of the glenoid was determined in the en-face clock face view of the glenoid. The grafts had a mean surface of 1.61 ± 0.51 cm(2) (mean ± standard deviation). The coracoid grafts were located between 01:05 hours (32.5°) and 05:33 hours (166.6°). Mean positioning was 02:00 hours (59.8° ± 16.1°) to 04:26 hours (133.0° ± 16.9°). The extent of the grafts was 73.2° ± 14.3°. The positioning of the coracoid graft on the clock face of the glenoid is situated in the decisive zone of 02:30-04:20 hours. The mean surface of the graft is smaller than expected from anatomical studies, but restores in defect situations bone stock in the potential defect areas at the anterior glenoid rim. Level IV, prospective case series, treatment study.

The aim of this study was to investigate the histological features of the remaining fibers bridging the femur and tibia in partial ACL tears. Twenty-six ACL remnants were harvested from patients who had arthroscopic criteria concordant with a partial tear. Histological analysis includes cellularity, blood vessel density evaluation and characterization of the femoral bony insertion morphology. Immunohistochemical studies were carried out to determine cells positive for α-smooth actin and for mechanoreceptor detection. In these samples, a normal femoral insertion of the remnant was present in 22.7% of the cases. In 54% of the samples, substantial areas of hypercellularity were observed. Myofibroblasts were the predominant cell type and numerous cells positive for α-smooth actin were detected at immunostaining. Blood vessel density was increased in hypercellularity areas and in the synovial sheet. Free nerve endings and few Golgi or Ruffini corpuscles were detected in 41% of the specim...

Quality control is receiving increasing attention from surgeons as a key to meeting the needs of patients and the requirements of health care authorities. The objective of the study was to evaluate a continuous monitoring program for surgical performance in anterior cruciate ligament reconstruction. We measured the differential anterior knee laxity immediately after anterior cruciate ligament reconstruction by two experienced surgeons. Surgical technique including the choice of ancillary devices and implant material was at the surgeon's discretion. The target was an immediate postoperative differential knee laxity at 20 degrees of knee flexion of -1.5 mm. The cumulative summation test (CUSUM) was used to detect inadequate performance. Seventy-nine consecutive patients were included in the study. Median postoperative differential knee laxity at 20 degrees flexion was -2 mm (interquartile range -4 to 0 mm; SD = 2.3). The CUSUM test at 20 degrees knee flexion emitted an alarm at the 12th procedure, indicating that performance was inadequate with a tendency for laxity to be above the target of -1.5 mm. Two alarms were emitted after the 28th procedure, indicating that laxity tended to be below the target. Monitoring of immediate postoperative differential anterior knee laxity in anterior cruciate ligament reconstruction is feasible and can provide useful information on actual surgeon performance. continuous monitoring of the quality of anterior cruciate ligament reconstruction may help surgeons to detect deviations from optimal performance when new surgical techniques and innovative fixation devices are introduced.